Incidence, Risk Factors and Prognosis of Contrast-Induced Acute Kidney Injury in Acute Heart Failure Patients Undergoing Coronary Angiography

Abstract

Background and objectives: Heart failure (HF) is a well-known risk factor for contrast-induced acute kidney injury (CI-AKI). We sought to evaluate the risk factors and prognostic impact of CI-AKI in patients with AHF who undergo coronary angiography (CAG).

Methods: A total 594 patients with AHF underwent CAG from May 1, 2011 to December 31, 2013. CI-AKI was defined as an increase ≥25% or ≥0.5 mg/dL in serum creatinine at 48 hours after CAG or the initiation of dialysis after CAG. The deviation of body weight on CAG day from the dry weight (ΔBWTCAG, %) was calculated for each patient.

Results: Overall, CI-AKI was observed in 24.7% of patients. Patients with CI-AKI had higher in-hospital death (16.3% vs. 5.1%, p<0.001; relative risk [RR], 2.50; 95% confidence interval [CI], 1.45-4.31) and 1-year post-discharge death (38.1% vs. 17.4%, p<0.001; hazard ratio, 2.16; 95% CI, 1.40-3.34) than those without CI-AKI. Patients with CI-AKI had greater ΔBWTCAG than those without CI-AKI (5.5±5.7% vs. 3.7±4.0%, p<0.001). A J-shaped association between the risk of CI-AKI and ΔBWTCAG was noted. In patients with weight excess (n=179), an increase of ΔBWT by 1% was associated with 9% (RR, 1.09; 95% CI, 1.03-1.16), while in patients with weight deficiency (n=86), a decrease of ΔBWT by 1% was associated with 11% increased risk for CI-AKI (RR, 1.11; 95% CI, 1.05-1.17).

Conclusions: In AHF patients undergoing CAG CI-AKI is common and associated with worse clinical outcomes. Achieving optimum body weight before CAG may reduce the risk of CI-AKI.

Trial registration: ClinicalTrials.gov Identifier: NCT01389843.

Keywords: Acute heart failure; Acute kidney injuries; Body weight; Contrast media.

Conflict of interest statement

Conflict of Interest: The authors have no financial conflicts of interest.

Copyright © 2019. Korean Society of Heart Failure.

Figures

Figure 1. Risk of CI-AKI and body weight deviance on CAG day. (A) ROC curve of %ΔBWTCAG to predict CI-AKI vs. no CI-AKI in whole study group revealed 3 zones of ΔBWTCAG with distinct classifying characteristics (left upper panel). In optimum zone, %ΔBWTCAG was a poor predictor (AUC, 0.50; p=0.99) (right upper panel). In excess zone (left lower panel) and deficiency zone (right lower panel), %ΔBWTCAG was a significant predictor with opposite direction (excess zone; AUC, 0.65; p<0.001: deficiency zone; AUC, 0.72; p=0.001). (B) Predicted probability of CI-AKI according to relative body weight deviance from dry weight on CAG (%ΔBWT on CAG). The solid black line represents predicted risk. The light-blue area represents 95% confidence interval. There is a J-shaped relationship between the risk of CI-AKI and ΔBWTCAG; the risk is lowest when ΔBWTCAG was around 0%.

AUC = area under the curve; BWT = body weight; ΔBWTCAG = deviation of body weight on coronary angiography day; CAG = coronary angiography; CI-AKI = contrast-induced acute kidney injury; ROC = receiver operating characteristic.

Figure 2. Clinical outcome. (A) CI-AKI and clinical outcomes: Patients CI-AKI had higher all-cause mortality than those without CI-AKI. In addition, there was no difference in mortality between patients with persistent and those with improved CI-AKI. (B) Body weight on CAG day and outcomes: patients with weight excess and weight deficiency on the CAG day had higher all-cause mortality compared to those with weight optimum.

CAG = coronary angiography; CI = confidence interval; CI-AKI = contrast-induced acute kidney injury; CV = cardiovascular; HR = hazard ratio.

Figure 3. Subgroup analysis. The forest plot depicts the association of %ΔBWTCAG and the risk of CI-AKI in each subgroup.

ΔBWTCAG = deviation of body weight on coronary angiography day; CI = confidence interval; CI-AKI = contrast-induced acute kidney injury; CKD = chronic kidney disease; GFR = glomerular filtration rate; HFrEF = heart failure with reduced ejection fraction; HFpEF = heart failure with preserved ejection fraction; OR = odds ratio.

Figure 4. Optimal timing for CAG to prevent CI-AKI. Renal perfusion pressure is determined by mean arterial pressure and central venous pressure. The probability for CI-AKI is lowest when the patients achieve their body weight optimum on the day of CAG, i.e., euvolemic state.

ΔBWTCAG = deviation of body weight on coronary angiography day; CAG, coronary angiography; CI-AKI = contrast-induced acute kidney injury; CVP = central venous pressure.